Intracardiac Thrombosis and Heart Failure in a Patient with Hepatocellular Carcinoma and Cardiac Amyloidosis and an Implanted Cardiac Resynchronization Therapy Device

Abstract

Patient: Female, 68 Final Diagnosis: Hepatocellular carcinoma Symptoms: Shortness of breath Medication: — Clinical Procedure: Cardiac resynchronization therapy Specialty: Cardiology Objective: Diagnostic/therapeutic accidents Background: Intracardiac thrombosis has been known to be associated with not only hepatocellular carcinoma but also with amyloidosis and use of a cardiac implantable electronic device. We report a case of a continuous tumor thrombus with hepatocellular carcinoma from the portal vein and hepatic vein to the right atrium via the inferior vena cava in a patient with a cardiac amyloidosis and an implanted cardiac resynchronization therapy (CRT) device. Case Report: A 68-year-old female first admitted to our hospital because of heart failure with an AL type primary cardiac amyloidosis. After 3 years, she underwent an implantation of a CRT device for biventricular pacing following repeated episodes of heart failure and low left ventricular ejection fraction of 34% with NYHA class III. Again, she presented with symptoms of heart failure and cardiomegaly on chest x-ray at 7 years after the CRT device implantation. The echocardiography showed a huge echogenic mass occupying the right atrium, and 64 multi-detector computed tomography showed a lobulated heterogeneously enhancing mass of hepatocellular carcinoma in the right upper lobe of her liver and a continuous tumor thrombus from the portal vein and hepatic vein to the right atrium via the inferior vena cava. Conclusions: Intracardiac thrombosis and heart failure occurred in a patient with hepatocellular carcinoma and cardiac amyloidosis, who had an implanted CRT device, which resulted not only in hypercoagulability by the hepatocellular carcinoma itself and the accumulation of various risk factors, but also the progression of myocardial damage with the development of amyloidosis.

Anticoagulation in Patients with Heart Failure and Sinus Rhythm

“…Although no epidemiological data on intracardiac thrombosis exist for heart failure, intracardiac thrombosis is relatively common in clinical practice and is frequently reported in case reports, especially in patients with significantly decreased LVEF. [38][39][40] Intracardiac thrombus may exist in the left cardiac system, right cardiac system, or both. Although a thrombus located in the left cardiac system is prone to causing systemic embolism, a thrombus located in the right cardiac system is prone to inducing pulmonary embolism.…”